Both Medicare and Medicaid have national “medically unlikely edits” (MUEs) in place that are designed to automatically deny claims that exceed specific daily limits. An MUE is the maximum number of units of service reported for a CPT code on the vast majority of appropriately reported claims by the same provider for the same beneficiary on the same date of service. MUEs should not be confused with annual utilization limits that we have seen from many commercial payers. MUEs are established by CMS as part of the National Correct Coding Initiative (NCCI) to prevent overutilization. Accordingly, understanding these daily limits can help practices avoid claim denials. Allergists should be aware of the following MUEs associated with these commonly billed CPT codes and the following MUE Adjudication Indicators (MAI). For the following commonly used codes, only MAIs of “2” and “3” apply. There are few MAIs that are Line Edits (MAI 1).
- MUE Adjudication Indicator (MAI):
- 1 Line Edit
- If you provided medically necessary UOS that exceed the MUE value, you may report separate line-item(s) with the same CPT/HCPCS code and a modifier.
- 2 Date of Service Edit: Policy
- These are “per day” edits based on policy (e.g., anatomic considerations, definition of the code, or published CMS policy). CGS won’t pay for services that exceed the MUE value.
- 3 Date of Service Edit: Clinical
- These are “per day” edits based on clinical benchmarks. CGS may pay for services that exceed the MUE value if you appeal a claim denial and provide adequate documentation to support the medical necessity of correctly reported units.
- 1 Line Edit
| Code | Description | Medicare and Medicaid MUE (Per Date of Service) | MUE adjudication indicator or “MAI” |
|---|---|---|---|
| 95004 | Percutaneous tests (scratch, puncture, prick) | 80 | 3 |
| 95012 | Expired Nitric Oxide | 2 | 3 |
| 95017 | Venom skin testing | 27 | 3 |
| 95018 | Skin testing for drugs and biologicals | 19 | 3 |
| 95024 | Intracutaneous tests/allergenic extracts | 40 | 3 |
| 95027 | Intracutaneous sequential and incremental | 90 | 3 |
| 95028 | Intracutaneous/allergenic extracts/delayed reaction | 30 | 3 |
| 95044 | Patch test | 90 | 3 |
| 95076 | Ingestion challenge/initial 120 minutes | 1 | 2 |
| 95079 | Ingestion challenge/each additional hour | 2 | 2 |
| 95144 | Allergy immunotherapy /single dose vials | 30 | 3 |
| 95145 | Venom immunotherapy/1 venom | 10 | 3 |
| 95146 | Venom immunotherapy/2 venoms | 10 | 3 |
| 95147 | Venom immunotherapy/3 venoms | 10 | 3 |
| 95148 | Venom immunotherapy/4 venoms | 10 | 3 |
| 95149 | Venom immunotherapy/5 venoms | 10 | 3 |
| 95165 | Allergen immunotherapy/multi-dose vials | 30 | 3 |
| 95170 | Allergen immunotherapy/whole body extract | 10 | 3 |
| 95180 | Rapid desensitization/each hour | 6 | 3 |
For example, if you bill Medicare or Medicaid for more than 80 percutaneous skin tests (95004) on a given day, you may receive a denial. Likewise, billing more than 30 doses of allergen immunotherapy (95165) may also trigger a denial.
Allergists can bill Medicare and be paid for units exceeding MUE limits in extraordinary circumstances, provided the services are medically necessary and documented. However, the claim will likely be denied. You should be prepared to appeal and supply the documentation to support the extra units of medically necessary services. Download the College’s sample MUE appeal letter for 95165. Additional details are available in CMS’s MLN Matters.
It is also important to remember that, for payment/billing purposes, Medicare defines a dose of 95165 as 1 milliliter (ml). Because Medicaid is a state program, policies vary from state to state. If your state Medicaid plan adopts the same policy on the definition of a dose as Medicare, the Advocacy Council may be able to provide guidance for a discussion with Medicaid payers.
Finally, a denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of an Advance Beneficiary Notice (ABN) will not shift liability to the beneficiary for units of service (UOS) denied based on an MUE.
For more coding information, check out the College’s Coding Toolkit and Coding FAQs.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
